=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457192783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONORAN DENTAL STUDIO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 865 S WATSON RD STE 201
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-3469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-242-4205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15813 W ALVARADO DR
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-7587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. FRANCISCO FELIPE MASCARENAS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 623-242-4205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------